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Monday, November 25, 2013

prokinetic

Hello gadabouts! Sorry for the recent long-form radio silence, but my current schedule allows a few hours each week for generative activities, and two weeks ago it occurred to me that I was scheduled to give Grand Rounds to my department at the beginning of December. Am scheduled. Also, we don't technically call them "Grand Rounds," rather "Education Lecture" or (perhaps more to the point) "CME-Getting Exercises"; but I just continue to call them "Grand Rounds" for ease of reference.

Upon hearing that I was giving a lecture soon, and perhaps more thrillingly, that I would be giving my talk off a series of PowerPoint slides (well, Keynote if you want to get brand-specific), Cal got very excited, because--and I don't know if I've ever shared this particular quirk of his on the blog itself--CAL LOVES MAKING POWERPOINT SLIDES.

CAL

What are you doing? Can I help? Maybe I could make your slides for you!

MICHELLE

Well, maybe I'll pick a slide or two and you could help import the images or something, but a lot of it I think I'm going to need to do myself, because it's kind of technical. You know, science-y.

CAL

Like what?

MICHELLE

Well, like I have to look at a lot of scientific journal articles, and pick the information to present, and it might be a little complicated for you to understand at this point.

CAL

I can do that. What's the talk about?

MICHELLE

Well, it's about developing a standardized protocol for treatment of postoperative nausea and vomiting.

CAL

What's that? The last part, I mean.

MICHELLE

Postoperative...well, it means...sometimes after people have surgery, they feel nauseated, and they barf a lot. So it's about what kind of treatments we have to prevent barfing.

CAL

Your talk is about barfing.

MICHELLE

Well...kind of, yeah.

CAL

(Reverently)

Cool.

So anyway, my point being that the few hours I've had per week for generative activity has been shunted away from the blog and towards getting my barf talk together. Of which I've spent maybe way too much time deciding (between wading through RANDOMIZED CONTROLLED TRIALS and META-ANALYSES and CONSENSUS GUIDELINES of course) whether I should include this picture on one of the slides.

So...probably no, right?

* * *

Well, in other news from the world of Cal:

As some of you may already know, two weeks ago Cal broke his left clavicle at school. He's fine, didn't need surgery (as you can see from the film there is clearly a break but it is not displaced) and just needs to wear a sling for three weeks while avoiding cage-fighting for six weeks total.

Cal's story is that he and a friend were playing tag at recess, when another kid ("A fifth grader," he told me ominously, as if that explained EVERYTHING) playing a parallel game accidentally tripped him mid-run, and down he went. And that's fine, these things happen, I'm certainly not blaming anyone (Cal, the fifth grader, any of the teachers) for the fact that Cal broke his clavicle, because that's what happens when you don't encase your kids in a Beanie Baby box and perch them on a shelf For Display Purposes Only.

I also don't blame the school nurse for not making the diagnosis of a broken clavicle when he reported to her office after recess, though--and I say this charitably--it was not a subtle diagnosis. Or...well, you tell me. A kid falls hard onto his left shoulder on the concrete of the school playground, a fall witnessed by his teacher, after which point his shoulders are asymmetric (like the left one is significantly lower than the right), he can't lift his left arm, and is crying about pain while pointing to the exact spot over his left clavicle where a clear angled deformity can be seen through the skin. Even so, I don't begrudge someone for not making that diagnosis, as clear as it may have been to me and anyone (including, may I add, the twenty or so elementary school kids who were shouting at me out the schoolbus window, "Cal broke his arm at school today!"). School nurse? Maybe more attuned to diagnosing disease of the infectious and rapidly-spreading variety than the orthopedic? Fine. I'll give you a pass.

But what I do mind? I do mind that fact that I didn't get a single call about Cal's injury--not one single call, text, e-mail, anything--and in fact did not know anything had happened until I picked him up at the bus stop and received him wincing down the bus steps, in tears, his friend carrying his backpack for him because even a fourth grader could tell Cal could not carry it himself. That the school nurse basically told him to walk it off and sent him back to class, where he sat for two more hours with a broken clavicle without me or Joe--both of us listed as emergency contacts and both of us never without our cell phones--getting single call so that could pick him up, check him ourselves, and cram in some Tylenol before taking him to the emergency room for a plain film to confirm what we could clearly see with our non-X-ray vision. THAT I DO MIND.

After he got back from the ER and we knew that he didn't need surgery, I wrote an e-mail to the principal to let him know about the situation. And again, I wanted to be perfectly clear what exactly it was that I was upset about. As a medical professional, I am more than aware about the perception of Asshole Patient Syndrome--namely that medical people sometimes expect unreachably high standards on their own medical practitioners, and can be, well, assholes about their own care or the care of their children. I reiterated that I was obviously holding no one to blame for Cal's accident (I think I may have used the phrase "these things happen" not one but three times in that e-mail, mostly as code for "DON'T WORRY I'M NOT GOING TO SUE YOU") and I again reiterated that while the fracture was quite evident, I did not hold the school nurse to the same standards of diagnostic acumen as an ER nurse or even a first year medical student. Fine. Maybe it wasn't obvious when it happened. Maybe it looked worse three hours later. Whatever.

But I made a strong point that I was very dismayed (while, I hope, aggressively maintaining the mien of cordiality tinged with disappointment about the school's interpretation of in loco parentis) that although this was the kind of injury we should have been informed about, preferably close to the time it happened or at least at the point that he was in the nurse's office; we did not hear one word from the anyone at school even after that downward dog-shaped clavicle ambled off the bus in a miasma of osteoblasts and tears. In fact, if I hadn't e-mailed them, I probably would never have heard about the event, except from Cal himself.

And frankly, we might never hear about it again. I just suggested to the principal, nicely (I thought) that he review with his school nurse what kind of medical events should trigger a call to a student's parents. He e-mailed back (addressing me as "Dr. Au"--I specifically did not make a point that Joe and I were medical professionals for fear that it would come off badly but either he knew that from our file or he saw it in my e-mail footer) that he would "look into it." And I can only assume that he has, since he hasn't e-mailed me back any follow up since.

In the weeks that have followed, whenever I pick up Cal from school and walk by the administration, all of them know his face (or perhaps recognize his sling) and exclaim to him with bluff cheer, "HEAL UP THERE, BIG GUY!" and "LOOKING GOOD! FEEL BETTER!" But never, not even as an aside to me, has anyone ever mentioned any kind of addendum to our e-mail exchange, or apologized to me for not being contacted in the first place. Honestly, I don't even want an apology at this point for not being called, because that's somewhat beside the point. But some follow-up would be nice.

So my question is this: what would you have done in this situation, keeping in mind that I don't want anyone to be punished or lose their jobs or anything like that--I just want to make sure that no other kids break bones or have seizures or swallow chicken bones and have to sit writhing in class for two hours. Also: do you think that the fact that Joe and I are doctors makes any difference in a negative way, in the sense that it gives the impression, warranted or not, that we are holding the school nurse to unfairly high standards?

72 comments:

PLEASE include the Exorcist image in your presentation! I'm a patent attorney and I try to put anything amusing into my incredibly dry lectures on patent law.

Coming from a similar perspective where I try not to mention that I'm a lawyer so people don't think I'm threatening to sue them, I would have tried to approach it similarly in the beginning. With no response to the email, though, I'd probably follow up with something more forceful that cited statistics about schools being sued for failing to notify parents. It may not be the best move, but they're being exceptionally unreasonable by not later addressing your issues. Also, they should really change their notification standards.

I find that schools especially public schools are quick to call you if your child is throwing up. However for all other matters including discipline matters they prefer not to communicate with parents. Boy, that came out bitter. For people who teach our children to communicate, I find them not very good communicators with parents. I would follow up with the Principal.

As a matter of fact, my third-grader broke his arm at recess two weeks ago. It wasn't an obvious break, but the fact that he couldn't raise his arm was concerning to the school nurse when she examined him. She immediately called me (she had to work through several contact numbers to track me down because I'd inadvertently left my cell phone in the car) and told me point blank to get his arm x-rayed. My kids have had a garden variety of playground injuries at school over the years, and the nurse always calls the parents about them, even if she is just going to send the kids back to class, so that the parent knows about the injury and can monitor the child at home.

I would also schedule a meeting with the principal and nurse, and with your background, maybe suggest they come up with a more effective protocol and procedure for when serious injury occurs on their grounds. If they acted the way they did with Cal's injury, sadly, it's just a matter of time with something else happens and next thing they know, a law suit is being thrown their way.

If they still don't follow up with you, you can always take it to "that level" as my mother calls it, where you contact the superintendent or the school board.

On another note, I am glad you all are having a talk about ways to prevent all the nausea and puking after surgery. When I had my knuckles replaced 3 years ago, post op was horrible. I have NEVER thrown up so much in my life. As happy as I am to have my right hand done next summer, I am quite anxious about the possibility of being sick after surgery like I was before.

If thee fact that you and Joe are doctors matters, it shouldn't. Foremost you are Cal's parents and if he is hurt enough to be exhibiting pain even a half hour later you should have been called. In the least the nurse should have iced it and called. Generally I was called if my kids skinned their knees. If my kid was sent home with a broken bone I would have raised hell. Generally best practice is to start gentle, but leave options open. Even if they think you can go over their head they are more likely to act.

No, you are not holding the nurse to unfairly high standards and you most definitely should have received a phone call. A thorough review of their call-the-parents SOP is in order. And, really, he can't raise his arm?! A nurse of school-aged children should be capable of recognizing that isn't normal! I agree, meet with the principal.

So sorry this happened to Cal. I had a similar situation in kindergarten where the teacher wouldn't send me to the nurse despite not being able to use my hand the rest of the school day post-recess when another kid tackled me into a ditch and wouldn't let me up despite my screams. I still remember it vividly. When I got off the bus I cried to my mom who upon observing my mangled fingers unleashed her wrath on the teacher and the school. I still have an overall bad memory of my kindergarten experience and other offenses the teacher did. Years later I heard she ended up blind at a relatively young age. Hmmmm...Anyway good for you for speaking out and I still think they owe you an apology.

You know what, the same thing happened to us when my son Chris poked his eye with the pencil tip. The nurse made him wash out his eye with water and sent him back to class. When he came home, he was complaining how sensitive his eye was to light and how he couldn't open it. The next morning we had to take him to the pediatrician and then got referred to a pediatric opthalmologist. Yep, not once did the nurse call or the teacher leave a note in his folder regarding this. I, unfortunately, did not contact the principal and I really should have. I guess school officials are too busy to let parents know of their child's injury. I think at the least they should send a note home, even if it is one of those fill-in-type forms, letting parents know if their child visited the school nurse and for what reason. You never know when it might be more serious that they think.

I would think that your being a doctor might make you more forgiving rather than more demanding - a non-doctor like myself might find a broken clavicle much more frightening and be more likely to want to speak in all caps (MY SON BROKE A BONE!). Definitely follow-up, if you are willing to spend the energy. You're doing the rest of the community a favour.

I would actually start with the classroom teacher. Yes, the nurse should have called. However, the teacher had a child in his/her classroom, in pain and probably in tears and could have contacted you at any time that afternoon. Sad, I've had the opposite experience of school nurses calling for every little thing - I think that is preferable! Hope he is feeling better soon, and yes you should follow up with the school.

Yes, a meeting with you, the principal, the nurse and the teacher is definitely in order, for all the reasons mentioned above. As someone else said I think you're actually being extra reasonable and forgiving in this situation because of your background. Sometimes school nurses are new grads with no experience under their belt, which doesn't excuse anything of course, but the school needs to follow up with him/her and also with you.

On another note: would you be willing to share your PONV findings? I'm an ortho nurse and boy howdy do I get barfed on a lot.

Meeting with the principal and if he pulls the, "You're a doctor, stop overreacting," then superintendent, then letter to the editor. I can't remember if Cal is in public school, but if he is, nothing gets Southerners all riled up like a good letter to the editor. I know you're worried about being THAT MOM and are overcompensating with the non-threatening, non-doctor role, but seriously, they messed up. Two hours sitting with a broken clavicle?! What. the. eff.

OhMahGosh - can't believe that happened! I think the principal has had ample time to respond. I'd send off an email to the superintendent. I don't think your profession would play into this at all - no excuse that by now you haven't received an acknowledgement re: lack of communication and how things will work going forward, with or without an apology. Infuriating! Also: need recipe for your chili.

First: I re-iterate what folks have said: you're justified in being miffed. Your concerns are valid that they're going to expect you to be extra-cranky on account of your profession (but their expectation itself isn't). People will always make assumptions, and educators encounter enough flavors of helicopter parent that they're probably very quick to assume. But, that doesn't mean you should try to over-compensate; their mis-perceptions are their problems, not yours. Personally, I think you're letting the school nurse off easy. If the worst thing that happens is that they become a little jumpy about making sure they over-communicate with you, that's better than things are now.

As a next step, I would email the principle again. It can be friendly and cordial, no big deal – just "Hello and thanks for looking in to it" ... "was just wondering what the outcome was?" ... "know you value communication with parents" ... "confidence that communication will flow more freely in future situations" ... "happy to come in and chat if that's more convenient than email", etc., etc.

I know of at least on principal who 1) has ADHD 2) is overworked 3) really bad with email. I'd operate under these sorts of assumptions about the radio silence, and continue to be a polite squeaky wheel... otherwise you're just going to worry that your kids aren't safe there.

You're being way too nice. When I was in elementary school, our parents got calls when we had fevers or even just unrelenting stomachaches. A serious playground injury with a visibly broken clavicle? That school RN needs to be fired. The principal needs to be reprimanded by the school board for not following up with you. And I'd seriously consider transferring my kid to a private school. Shit like that doesn't go down in private schools.

In addition to having that talk with the principal, maybe it's also a good idea to teach your kids that if they are in excruciating pain, they're allowed to request to call you too? Not that the onus is on an elementary schooler to self-diagnose, but self-empowerment is a good thing, too!

In your presentation you should include as patient if they have ever gotten sick from anasthesia. I've had 12 surgeries (don't ask) and only got sick after the first one. Before every other surgery I tell everyone I get sick and they load me up with zofran.

This made me crazy, because almost the exact same thing happened to me when I was a couple of years older than Cal, except it was a broken foot in gym class. I dragged my foot around in tears the rest of the day, and every single teacher I told laughed and said I should have been more careful. By the time I was picked up from school, the swelling was so bad that the ER doctors couldn't put a cast on it; I was sent home to ice it for 3 days first. My Dad handled the situation by speaking directly with the principal and saying pretty much what you said, "Hey, this stuff happens, but why did my daughter walk on a broken foot for 3 hours AFTER complaining about being in a lot of pain?" The school ended up offering to pay the medical expenses and putting rules in place about what to do if someone is in tears and unable to bear weight... And it wasn't laugh at the child and tell them to suck it up! As a side note, I was in a private school- this stuff can happen anywhere.

My grandaughter had an allergic reaction and school called me and said come get her she is having problems breathing and needs to go to the ER. I was there in about 10 mins, and expected them to have sent for an ambulance. No such thing she was wheezing, in distress and I whipped her up to the ER where they took her straight in and gave medication.The school were very blaise about things, but I was livid, in an allergic reaction situation, minutes count. They just poo poohed away.

I got a call that my kid fell and had a bleeding lip, that the bleeding had stopped, but they wanted me to know so that I wasn't alarmed when he came home with a swollen mouth. I would definitely arrange for a meeting with the principal about this. It's unacceptable.

I am with you that to not be notified when he couldn't lift his arm is not acceptable. They certainly notify parents when there is lice! I think, for parents everywhere, that you don't give up in understanding how the system failed Cal. Take care!

You're taking this much, much better than little old non-MD, avoided-biology-class-like-the-plague-in-high-school me. I do come from a long line of educators, though, and any educator/nurse/administrator who doesn't recognize when a child is crying in pain nor acknowledge a child's request for help is simply negligent. The principal really needs to be told that this isn't an acceptable situation, for Cal or for any other child in his care. I'm livid just thinking about any child having to sit in class for hours with a broken clavicle! So no, you're definitely not overreacting.

As a nurse, I want to point out that even new grads should recognize what you've described. I'm not sure what the laws are in GA, but here in NY you must be an RN to work in a school, unsupervised. An RN should be able to handle a playground injury, calls should have been made, and the principal should be offering to buff your shoes with his goatee at this point. Your profession has nothing to do with it. Your child sat crying with a broken f'ing bone for the rest of the day!!

Don't go easy on the principal and, PLEASE, don't go easy on the nurse. If she could overlook this, it could be something life threatening next time.

That's terrible. When my kids have had serious injuries at school (severely sprained ankle and--as it happens--broken left clavicle) there were multiple calls from the school (school nurse, apologetic principal) and both times the school's insurance picked up medical bills (they offered).

Heck. Two weeks ago when my six-year-old tripped getting into the school bus and hurt her lip, they called me to let me know what to expect... The behavior at Cal's school is unacceptable and also NOT the norm. Please use your medical professional status to make sure they review their practices.

(And yes, please use the exorcist still! The kids live to insert trippy pink elephants and stills from _The Shining_ into the spouse's med school prof lectures.)

I broke my collarbone in high school playing on the soccer team. It was the same kind of thing. I fell and everyone told me to get up, shake it off, get back out there. I asked to be subbed out cause I couldn't move my arm and my parents seemed embarrassed they had to walk me to the trainer. The trainer had no idea what my problem was but my parents did drive me to the ER where the doctors kept backing away from the xray saying, "wow, I could see that from here." "No, I could see that from HERE" Come to find out that it is the most common break and feel that the coach should have know that and especially the TRAINER. I mean, isn't that your job?

So, maybe there is just something about that particular break that is hard to diagnosis?

Unrelated story, at a fun run put on by the school, my son fell and bruised his, well, down there really bad and it was bleeding. The administration was unsympathetic when I asked if the nurse was around or if they had ice or a band aid. They were apparently behind me when I told someone else the people in charge were unhelpful and then suddenly were very attentive and called me at home to check on it. Very interesting.

Never had good experience communicating with my child's school. When trying to stop bullying, things got worse. I had to keep talking to teacher, then principle. And teacher started isolating my kid, ignoring kid in class. We had to change school. They will remember this incident for the rest of your time in that school. And your reputation of complainer will only make school less friendly for your kid, no matter how justified your complaint was. I wanted to prevent that, and initially kept communication verbal only. When it did not work I escalated to e-mails and principal meetings. Your writing an e-mail was a higher level of threat to the school, thus you should expect defensive reaction.

Oh, PLEASE include the Exorcist photo!On a parallel note, to share an amusing-now-and-not-nearly-as-serious-but-on-the-barf-topic-school-notification-horror-story:Three days before Christmas, Child A barfs onto Child B (mine). Child A is sent home. I discover this event from my daughter when she emerges from school smelling like a vomitorium. (And guess who no one would sit with/play with at lunch?) The spewage from Child A occurred at 9am; this is at 3:30pm. When I asked the principal why I was not contacted to (at the very least!) deliver clean clothing, I'm told that "the teacher scraped the chunks off of her clothes and tried to clean her up." So, problem solved? REALLY?Guess which family spent Christmas Eve/Christmas Day in the bathroom? Sure, it could have happened even if she did get clean clothing, but I desperately wanted to sentence that teacher to 6 hours of wearing vomit-covered attire. Don't expect a response/resolution. You can't fix stupid. Instead, teach Cal a little more assertiveness to insist you be contacted on his own if he is in pain.

That is so f-ed up what happened at school. Not surprising, I guess though. At least Cal didn't report that his teacher yelled at him to stop crying repeatedly. Is it bad that my expectations are that low?

WTF? I work in a small private school with no nurse, but as a teacher I would have immediately called you! Pain is hard to fake, and little kids are terrible fakers. Our policy is to email/send a note home for any minor injuries (scrapes, bruises, small cuts), call for anything on the head or face, and call for any suspected broken bones. I had a boy with nursemaid's elbow last year and we called any time he fell on his elbow. I would expect at the minimum a note home with the child saying they had been to the nurse's office, and a call for anything more than a minor cut or scrape.

I'll present the other side. This does not mean I disagree with you, merely that I'm presenting the other side.

I was a latchkey kid starting at age 6. Financially, there was no other option. One time, I think it was 4th grade, I was very sick but went to school anyway because it didn't feel that bad in the morning. It wasn't a broken bone, but it was a very high fever along with other symptoms. The school nurse called my mom to tell her to pick me up immediately. My mother worked 1.5hrs away, so by the time she would have arrived, the school day would be nearly over.

But the commute time was beside the point. At her job, taking or making personal calls could get you disciplined and even fired. There was an emergency contact on file, but when they called the emergency contact, there was no answer.

My mom told the nurse to send me home, as in, let her walk home (about 20 minutes). The school refused. So I stayed in the nurse's office until school ended, at which point I walked home, throwing up once along the way.

That night, my mom sat me down for a serious talk and chastised me for going to the nurse's office. She said that I knew she couldn't have picked me up and that it jeopardized her job (true, I did know but didn't completely understand the implications), and the school had said that if she didn't come, they would send me to the emergency room, and that would have put my family in major debt because we were uninsured.

After that, my mother put a fake work number for the school to call.

Looking back as an adult, I do regret going to the nurse's office that day, and I most certainly would have protested the nurse calling her, though I doubt they would have listened to me. My mom's job situation was truly that precarious that it would have been better for me to suck it up until the end of the school day.

If it were a broken bone the situation would probably have been different because you have to seek medical help, and you can't suck it up and wait for it to go away. But for a bad flu, I could have sucked it up and, knowing what I know now, I would have.

My best friend at the time suddenly moved at the end of the next school year, and I didn't know why until years later. He had gotten in trouble at school, and his mom was ordered to leave work and pick him up. The first time it was okay, but the third time she lost her job. Ironically, she was a nurse. At the same time, his father walked out on the family which consisted of three children, leaving them with a sizable mortgage. They lost the house and had to move in with the mother's parents in a different city.

It's perfectly reasonable to expect a note at the end of the day saying that the kid was in the nurse's office, and it's wrong that they didn't do that.

But in some situations, calling parents during the workday about every trip to the nurse's office can do more harm than good, and it can also make a child reluctant to ever visit the nurse again.

Again, I'm not disagreeing with you. I'm only saying that these decisions are more complex than you may realize.

I feel you are overly trying NOT to be all "I'm a doctor" about this because you are actually a doctor. Go get on them for not doing what you think is a normal thing and calling the parent about a kid getting possibly hurt at school. A parent of another profession could easily be like what you are worried of coming across as. aka, "WHAT THE HELL IS WRONG WITH YOU" slap the nurse on the wrist or something due to the not calling thing. And issue an apology letter or follow up on the changes based on what had occurred. Good for you to email the Principal but maybe something more is needed or email him again to ask if the changes had been made.

This is totally unacceptable and should be dealt with clearly and immediately by the school. If the Principal doesn't follow up soon I would strongly encourage you to contact him again. Or the board or whatever.

I teach kindergarten, so it's a little different than older students (I think there is typically a lot more school to home communication with younger students) but I'll give my opinion anyway if that's okay:) If you feel comfortable talking to Cal's teacher, I would mention the situation to her and how you would really like to be called in the future. I have had students who I call/email parents for often, and students who have parents that only want to be reached in a true emergency. Sometimes I learn through trial and error, other times parents communicate this to me. I think that you should have heard back from the principal, and communicating with him or the teacher for follow-up would be appropriate. It is really difficult because every child and situation is so different. I cannot speak to the nurse recognizing the break; that is out of my area of expertise. However, if a parent ever is feeling concerned I appreciate knowing so that I can do the best job possible down the road. I'm sorry this happened to your son and I hope that things get resolved quickly. Reading all the stories about people with similar experiences makes me sad; I don't think, and really hope, that families in my classroom and school are not feeling this way. The decision of calling/not calling is always a tough one but knowing where individual families stand makes it easier.

I remember my school nurse called home for EVERYTHING-granted, I was terribly allergic to nuts and bee stings and asthmathic, so she erred on the side of caution. If I got scraped up on the playground, a note home.

But in the day and age of email, you'd think that sending a quick email note to both you and your husband "Hey, just so you know, XXX happened. This is what we did so please call with any questions or concerns" would have been the BARE minimum.

Re: the picture, YES. Re: the nurse, that is some bullshit. I have gotten calls from my kids school nurse about things I wouldn't have thought twice about at home, and for the longest time, I thought that this was because she knew I was a nurse as well. Turns out, she calls everyone for every little thing. Given the choice between a call about a rash on my kids wrist that only she can see and not getting a call at all about a broken bone, I'll choose the call every time. Glad Cal is alright.

Former teacher here. Current elementary school parent. I do not think this was a complex call to make. There was an incident. He was hurt. He was in pain. He was visibly hurt. You should have been called. The principal should have emailed you back with information. Balls were dropped. I advise emailing the principal to follow-up and/or showing up with your husband to discuss. They know better. If the principal never responds, I'd email his boss to ask what your expectations should be around this type of thing. Completely unacceptable.

I am a physican and my husband is not. I think you're being overly sensitive / trying to compensate because you are both doctors. I'm pretty sure my husband would have had someone fired if something like that happened to our daughter. This is totally unacceptable and you shouldn't let it slide.

Dear Michelle: I love your blog. and must tell you that your decision to go part time inspired me a bit...I am also a physician w two youn g kids.

I also happen to be someone who is terrible at email in the sense that I use it expressively (or have, in the past) and so am experienced now in not receiving responses/ being shocked by people not responding/ being at times even outraged etc etc.

The one practical thing I can point out: when a certain kind of (often administrative) person gets an email that is expressive (in that it does not ask a yes/no question or a point blank question or make a clear demand for something - ie Could you please do X?) it is actually to be expected that the (adminsitrative) person doesnt answer.

The mindset seems to be:

a) Not answering leaves more options open. By not answering it leaves open the possibility of saying, if ever asked about the email: I didnt know you wanted a response; I thought the matter had been resolved; I didnt receive the email; The matter was internally discussed. Ie it leaves the maximum flexibility for the person receiving the uncomfortable email.

b) Almost 100 percent of the time, the email has in fact been read, discussed, debated, created anxiety, created a response, created planning etc. Ie in the email you are describing, re: pointing out a serious flaw in the communication and possibly the nursing evaluation system at the school, the principal most likely discussed the email with the legal department who advised him or her not to answer and to wait to see what you did next, if anything, and also wait and see that the child recovered normally. Ie once a response is sent, if God forbid there had not been normal recovery, then it bcomes part of a record that could be involved in legal action. Your saying these things happen might have meant, in your mind, that you dont want to sue, but in a legal mind, they might mean: you are thinking about suing or think taht you could have sued or at some point were angry enough to sue and talked yourself out of it.

c) If you want a response for sure, call the school and ask to speak with the teacher and principal. I dont think its as appropriate to speak directly to the nurse because there isnt the same relationship of ongoing comunication about ones child w/ a nurse vs the classroom teacher who is the responsible party, ultimately, for coordinating with parents.

I hope that helps. I have learned a lot about how to manage expectations around email and now have reached the point that I am just not going to use it for any emotionally weighted communication.And enjoy your chickees! They are adorable. Makes me hold my own two all the more tightly.

I agree, this is a very helpful post that makes me better understand why people don't respond to this sort of thing. Thanks. And Michelle, hope you have talked to the principal as all suggest. My kids have been in public schools for a total of 21 years and they have called about every tumble, scrape, wheeze, bump, and yes, a fractured arm.

The best course of action may be to bring this up at a PTA meeting. I have a feeling the administration will answer (or not) in whatever way they think is least likely to lead to a lawsuit rather than work toward a practical solution. At a PTA meeting, however, you can make the case to all the other parents and hopefully come to a consensus about standard operating procedure.

A clear policy needs to be in place about what types of nurse visits warrant immediate phone calls rather than a note at the end of the day that the child was seen at the nurse (something I think should be standard practice).

Then at the beginning of the school year, allow parents to elect to a) accept the default policy, b) request immediate notification for any nurse visit, or c) request immediate notification only for true emergencies.

As for worrying that you'll come across as an Asshole Patient physician, most of the non-medical world has no idea that asshole patient physicians are a phenomenon. If anything, you may be more likely to be taken seriously if you are a medical professional. So don't let that influence your actions.

Call them. It is so easy for an email to be (mis)interpreted in a number of ways. It is so easy to spend time writing a well-crafted email to display your point of view. But if you are looking for human compassion (and it seems like you are) start with human interaction. It is just as easy to call and talk to the nurse/ principal

I am a teacher. I would have called home. In fact, I have called home when the school nurse and other admin didn't. Even mother ignored me. Child was suffering from appendicitis and every one else ignored. Make a big deal. You have my permission. And I teach high school and see the kid for 45 minutes.

A similar thing recently happened to me with my 5 year old, where he fell from about 8-9 feet onto his wrist. When I picked him up a few hours later at the usual time, they mentioned it but said they thought he was fine. Unlike the above picture, he didn't have an obvious deformity, and he was keeping it together pretty well. So the call was a little more difficult without any experience, but I thought the school should know that with that mechanism of injury, they should expect a fracture. Like you, I didn't want the message to be about the injury itself, and I was sensitive that as a pediatrician I had to be more careful.

What was especially galling was that they had previously called me about a mosquito bite!

I am a former teacher, current mother and surgery wife. 1- send your kid to private school because you pay for the basic stuff of: call me when my kid breaks a bone 2- you have every right to be upset. it's quite patient and polite of you to not go in there raising hell like it's nobody's business 3- Joe SHOULD go up there and let them know his boy was hurt, this professionalism is bullshit and unbecoming of any school administrator and lastly 4- PUT HIM IN PRIVATE SCHOOL. did i already mention that? i taught in the BEST most elite public school system in TX. (You know, big oil $ blah blah). You can't beat the individual attention at private school--end of story. Don't feel like a snob for public school NOT being good enough. Now is the time to find your spine, curse that principal and send your business elsewhere. They love your son for his brains and test scores but nobody, not even the teacher, has the decency to CALL you? that is code behavior for: I don't care about your kid, period. Trust me, I would know. There were so many POS teachers I worked with that I can't get into details of how awful they were to kids who deserved it much less kids who did NOT deserve it. You can't say there weren't warning signs if something worst happens--and it can. Do NOT kid yourself one bit. All school personnel from principal on down are over worked, underpaid and many of those in public education are just complete worthless folks who have a sensitivity chip missing. Again, trust me, I would know. Nobody wants to take that extra step of being human because they might get sued or sucked into some drama that takes away from their life and being a teacher already means you work an extra 20 hours a week for free. It's kind of like residency except the pay never improves and the quality of your patients goes down as you progress through your career. Move schools NOW and never look back. TRUST ME.

FWIW, I worked at a boarding school where parents paid as much as they would for a private college education. The staff there were overworked and underpaid, and the "nurse" they had wasn't actually a licensed nurse. Her degree was in journalism, I believe. All of us staff were told to keep that quiet.

Not all private schools are created equal. You have to do your homework. The most expensive school in my city is the worst in my professional opinion. They don't have strong academics and their social dynamics are obnoxious. It's where the dumb rich kids go. You are right that there are imperfections in private school however, if you find a private school that "fits" your family they will most definitely listen and do the appropriate thing when an issue arises whether it's after the fact or before something becomes an issue. Public schools are dying a slow miserable death. That principal sounds like a jerk and no complaining TO him or HIS PTA will be worth your while. HE knows who HE hired and everyone knows who the crummy staff are and who the good staff are. Everyone knows who not to piss off (school secretary and possibly school nurse and sounds like your son's teacher is a jerk too for not caring enough to call you). So do what you want but that kind of crap would NEVER be tolerated in a private school that would value my money because I'm not the type of person to want to go to the "best" simply because it's "the best". I decide what is worth my time and money and public school with jerks like that are not worth my time.

I love how this has turned into a private vs public school debate. We are in an under-resourced public school in San Francisco, don't even have the funding for a school nurse, and we still get called about every little bump. Fine, the nurse might have been an idiot, but the teacher or the principal should definitely have called you.

When I was a fourth-grader, I destroyed my arm by falling of a slide. Perhaps because it was a private school or maybe because my whole arm was an amorphous mess that was obviously, exceptionally broken, nearly every administrator called every number listed for my family. Not being able to get a hold of my parents, the principal and one of the school nurses DROVE me to the ER. I woulds say it was a pretty good experience, though I was a little mortified as a fourth grader when the ER tech asked if the Principal was my dad. I'm not ultimately sure why, now...but you know.. I was eight.

Wow. You're right to be upset! Schools employ nurses to attend to sick/injured kids, rather than random admin assistants, because nurses are health professionals who are supposed to be able to accurately assess situations precisely like this! (In a way, it's even kind of insulting to nursing as a whole to suggest that it was reasonable for the school nurse not to have been able to deal with this appropriately.)

Good Lord Michelle! I'm so sorry to hear this happened. That nurse should be FIRED for not recognizing the fracture or seeing a need to contact you. If my kid were made to sit for hours in pain due to someone's utter incompetence there would be hell to pay. I would ask for a meeting with all involved to hear their version of events. If unsatisfied, I'd talk to a reporter for your local newspaper. That way the entire community can weigh in on how to handle the matter.

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I am a former teacher, Group current mother and surgery wife. 1- send your kid to private school because you pay for the basic stuff of: call me when my kid breaks a bone 2- you Amateur Porn have every right to be upset. it's quite patient and polite of you to not go in there raising hell like it's nobody's business 3- Joe SHOULD go up there and let them know his boy was hurt, this professionalism is bullshit and unbecoming of any school administrator and lastly 4- PUT HIM IN PRIVATE SCHOOL. did i already mention that? i taught in the BEST most elite public school system in TX. (You know, big oil $ blah blah). You can't beat the individual attention at private school--end of story. Don't feel like a snob for public school NOT being good enough. Now is the time to find your spine, curse that principal and send your business elsewhere. They love your son for his brains and test scores but nobody, not even the teacher, has the decency to CALL you? that is code behavior for: I don't care about your kid, period. Trust me, I would know. There were so many POS teachers I worked with that I can't get into details of how awful they were to kids who deserved it much less kids who did NOT deserve it. You can't say there weren't warning signs if Hardcore something worst happens--and it can. Do NOT kid yourself one bit. All school personnel from principal on down are over worked, underpaid and many of those in public education are just complete worthless folks who have a sensitivity chip missing. Again, trust me, I would know. Nobody wants to take that extra Siyah Peynir step of being human because they might get sued or sucked into some drama that takes away from their life and being